Best resources on scale up, replication and institutionalization….

**Updated in 2017, including a new resource on scaling up social enterprises, see below.

When we look at current inequities in access to essential health services, scale up, and targeting of existing programs to those most in need, becomes imperative. Recognizing the urgency, national government and international agencies have committed to scaling up successful interventions to meet the SDGs.

Scale up is defined as “deliberate efforts to increase the impact of health service innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a lasting basis” (Simmons 2007)

I became passionate about scaleability when I saw so many health behavior practitioners designing, implementing and evaluating small-scale intervention projects, with little heed to the systems context. Some community-based interventions should be small and culturally and socially specific, but generally, this seemed an uneconomical approach, generating data of limited utility in creating a healthy population. If pilot interventions could be conceived with a view to scaleability from the outset, then their value for the population at large would increase.

Happily, in my professional work I keep bumping into issues of scaleability. Monitoring and evaluation is primarily put in place to assess effectiveness – to see if the project should be scaled up or replicated. Documentation is done to identify key steps and lessons learned, with a view to scale up. A lot of advocacy work focuses on getting government to adopt a particular product for scale up. I developed a KM strategy for the Sukshema Project whose sole purpose was to promote scale up.

What I have seen is that while scaleability is a central issue in public health, it is often approached haphazardly. If it can be made a more explicit goal it can be approached purposefully and strategically. This is important, as many public health interventions are highly dependent on specific and complex organizational contexts (less so with products, such as IUDs), and scale needs careful thought.

For this reason I have compiled a list of the best resources devoted to scale up. Many of these I have used before, but I also found a few new ones….I hope this compilation is helpful!

I found this document very useful in outlining the key steps and elements for creating a scale up strategy. The five elements include; the innovation itself; the individuals and institutions facilitating its wider use; the scale up strategy; the users of the innovation; and; the environment in which the scale up is taking place.

At each step, the guide poses key strategic questions that can be answered together with the implementation team through a participatory process, and then suggests clear actions that can be taken.

I was happy to find this resource! Often pilot projects are implemented by NGOs with a specific culture and values – frequently including a transformative approach to gender norms. And at scale up, the intervention is likely to be taken over by the government health system or another large organization that does not have the same culture or values. Most guidance available on scale up suggests streamlining programs to their most essential components for scale up – and it is easy to see how a focus on gender may be jettisoned.

This paper is based on case studies and a literature review to assess how gender is incorporated during the scale up process – even if it is not part of the pilot. It identifies a number of lessons learned from scale-up initiatives and lists key recommendations for systematically integrating gender into the scale-up process. As much as anything else, it serves as a reminder to try and keep gender front and central.

This resource focuses on the policy aspect of scale up, a component that is often called “vertical” scale up. It makes the point that both national policies (what the document refers to as big P policy), implementation plans and operational guidelines (little p policy) need to be incorporated into scale up plans from the beginning. Without attention to the policies that underlie health systems and health services, scale-up is not likely to succeed. The article identifies key actions to ensure supportive policies:

This is an excellent and comprehensive management framework. It advocates planning for scale up from pilot conception, and creating a clear vision between all parties. To anticipate scale up, the framework suggests the following elements be incorporated into the original design and implementation of the pilot project; documentation of the model; a strong M&E plan; dissemination of results; and, stakeholder engagement. It also suggests identifying and filling information gaps on the part of the decision makers.

This framework also puts pressure on the M&E plan for a pilot intervention. It must tell us why the project is successful; an assessment of the models strengths and weaknesses; cost-effectiveness; and a comparison with alternative models. It also suggests an external or independent evaluator.

Useful tools within the framework include as assessment of scalability checklist (table 3), I am not sure if a scorecard or narrative answers are more useful for such a tool.

Technical people I speak to in my work around scale up put cost effectiveness as front and centre on any decisions about going to scale. Considering good quality cost effectiveness data is frequently not available, I expect many decisions for scale up are made without it, however there is no doubt it is important.

This is a journal article based on a review of the literature, and lists factors that influence cost of scale up. A lot of the other resources I have listed here are for facilitators of partipatory processes around planning for scale up, and so have a certain motivational quality about them – they are attempting to create a common vision with a team. This article is helpful in that is based on real data, although its findings resist any generalizations and do not identify elements that are transferrable.

The article highlights that cost variations of interventions going to scale vary according to the type of intervention or setting, making it difficult to create a typical cost curve. Some of the key trends identified are; costs will vary according to geography (rural/urban); the specific nature of the program needs to be understood to identify fixed, semi-fixed or variable cost; economies/diseconomies of scale should be identified; and, the cost of human resources is especially hard to project.

This is a great little document that helps simplify and streamline a project, suggesting that one of the main barriers to successful implementation and scale up is project complexity. I like this document because it is simple, accessible, and it’s a great little summary of lessons learned. From the document itself “When compared to standard health communications programs, we believe these principles save time and money without compromising quality. Time saved means quick start ups and rapid rollouts, which translate directly into improved impact.”.

This is specifically dedicated to the challenge of scaling up digital health and ICT projects, many of which flounder at the pilot stage. Authors focus on the issue of “institutionalization” – when a new technology is routinely used as part of the health system, as a proxy for scale. The document identifies leadership, an effective product, a viable economic model, a supportive policy environment, effective management, and capacity as the key determinants of human capacity.

“ExpandNet, in collaboration with WHO, has produced several guidance documents based on literature reviews and the extensive experience of its members, all captured in this toolkit. These tools are intended for policy makers, program managers, funders, project staff, and those providing technical assistance to scaling-up initiatives.” Some of the documents reviewed above are contained in this toolkit. All these documents are useful, but it is unlikely you would need all of them, they repeat the same concepts in different formats.

I love CORE Group! “This paper briefly summarizes definitions, approaches, and challenges to achieving “scale” in community-focused health programs as discussed at the 2005 CORE spring meeting and the USAID child survival and health grants program mini-university. This paper is meant to harmonize a vocabulary for use by NGOs and their partners as they further discuss, debate, and analyze how NGOs and their partners can reach more people with high quality maternal, child and neonatal health interventions.”

Esther Duflo argues that evaluation of pilot projects is an important precondition of scale up. For me this is so obvious, I almost couldn’t believe she spent 25 pages making the case. However, I have worked with multi-lateral agencies who do not give much time or resources to M&E data, and are not comfortable with it. I think the argument for this neglect is that their work is so urgent, everything must be done at scale at once. Of course, scaling up without proper M&E data can lead to terrible waste of resources. These agencies are so influential, I can see why this paper is important.

An important thing to note here is the quote “what works for 10 or 100 units may not work for 100,000” – the point being that an intervention working at scale will look different to a successful pilot. This is a short document that outlines that scale will take many different non-linear pathways and highlights many common hurdles for scale-up. Easy to read, it does not add much to the existing literature except brevity – an excellentl resource for those too busy for a deep dive.